Administrative — Insurance Appeal Letter Template
The Insurance Appeal Letter Template is an essential resource for physicians and healthcare providers writing appeal letters to contest insurance denials for medications, procedures, or services. This template provides the structured format and persuasive clinical language required to successfully appeal denials and obtain coverage for medically necessary treatments. The template includes sections for denial information including claim number and denial reason, detailed clinical rationale explaining why the denial was incorrect, additional clinical information not previously submitted, supporting clinical evidence and guidelines, expected outcomes and benefits of treatment, risks of not approving the appeal, and professional attestation. This template streamlines the appeal process, maximizes appeal success rates, supports revenue recovery, and protects provider time by standardizing documentation. The structured format is adaptable for medication appeals, procedure appeals, service appeals, and other types of insurance denials. Ideal for busy clinical practices, specialty care providers frequently dealing with denials, and administrative staff responsible for managing appeals.
Template
Letter Header
Provider name, credentials, practice name
Address, phone, fax, NPI
Date
Appeal Information
Claim number: [Claim number]
Date of denial: [Date]
Denial reason: [Reason stated by insurance]
Appeal level: First level / Second level / External review
Patient Information
Patient name, DOB, insurance ID
Diagnosis: [Primary diagnosis with ICD-10 code]
Requested service: [Medication, procedure, or service]
Clinical Rationale for Appeal
Why denial was incorrect: [Detailed explanation]
Additional clinical information: [Information not previously submitted]
Clinical necessity: [Why this is medically necessary]
Expected benefits: [How this will improve patient's condition]
Risks of denial: [Consequences of not providing treatment]
Supporting Clinical Evidence
Clinical guidelines: [Relevant guidelines]
Evidence-based medicine: [Studies or evidence]
Previous authorization attempts: [If applicable]
Provider Attestation
I respectfully request reconsideration of this denial. The requested [item/service] is medically necessary for this patient based on [clinical reasons]. I am available to provide additional information or discuss this case.
Provider Signature
[Signature, credentials, date]
Attachments
[Office notes, labs, imaging, prior authorizations, etc.]
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